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TNO Kwaliteit van Leven, voorheen TNO Preventie en Gezondheid, heeft in opdracht van het College voor Zorgverzekeringen (CVZ) een inventarisatie gedaan naar de standpunten van verschillende partijen ten aanzien van de directe toegankelijkheid van acht paramedische beroepsgroepen. In twee opeenvolgende artikelen worden de resultaten van het rapport Haalbaarheidsstudie Directe Toegankelijkheid Mondhygiënisten en Tandprothetici samengevat. In dit eerste artikel worden de standpunten van diverse landelijke organisaties weergegeven ten aanzien van de directe toegankelijkheid van de mondhygiënist. De betrokken organisaties zijn de Nederlandse Vereniging van Mondhygiënisten (NVM), de Nederlandse Maatschappij tot bevordering der Tandheelkunde (NMT), de Associatie Nederlandse Tandartsen (ANT), het Ministerie van Volksgezondheid, Welzijn en Sport (VWS), Zorgverzekeraars Nederland (ZN) en de Nederlandse Patiënten en Consumenten Federatie (NPCF). In het onderzoek werd specifiek gevraagd naar de haalbaarheid en wenselijkheid van de directe toegankelijkheid van de mondhygiënist, naar de voor- en de nadelen van de directe toegankelijkheid, naar de gevolgen voor het kwaliteitsbeleid en naar de mogelijkheid en wenselijkheid van het opstarten van proefprojecten. In het tweede artikel worden de standpunten van de in het veld werkzame mondhygiënisten en tandartsen beschreven ten aanzien van de directe toegankelijkheid van de mondhygiënist.

The number of recently published papers on motion sickness may convey the impression that motion sickness is far from being understood. The current review focusses on a concept which tends to unify the different manifestations and theories of motion sickness. The paper highlights the relations between ergonomic principles to minimise motion sickness and the concept predictions. The clinical management of sufferers from motion sickness in terms of selection, pharmacological measures and desensitisation courses is treated as well.

Elderly users are increasingly becoming active consumers of Internet technologies. Developing websites dedicated to this user group presents several design issues (such as that of 'design for all', participatory design, patient empowerment and cognitive usability assessment methods). SeniorGezond is a health information resource currently under development. It aims to support elderly users in their search and access of appropriate information in the area of fall incidences. The current development of SeniorGezond provides a useful illustration on how design issues can be addressed and applied in a practical setting. Copyright © 2004 Sage Publications.

Objective: To determine the influence of tutor expertise on the uptake of a physiotherapists' educational programme intended to promote the use of outcome measures in the management of patients with stroke. Design: Pilot randomized controlled trial. Methods: Thirty physiotherapists involved in stroke management were randomized into two groups and participated in five tutor-guided educational sessions (the Physiotherapists' Educational Programme on Clinimetrics in Stroke, PEPCiS). Groups differed from each other with respect to tutors: one experienced and one inexperienced in stroke care. Primary outcome was 'actual use' (the frequencies of data of seven recommended outcome measures in the patient records of the participating physiotherapists). Results: The actual use of instruments shifted from a median of 3 to 6 in the expert tutor group and from 3 to 4 in the non-expert tutor group (P = 0.07). Physiotherapists educated by the expert tutor used a broader variety of instruments and appreciated the educational programme, their own knowledge gain and all three scales of tutor style aspects significantly more than their colleagues of the non-expert tutor group (all P<0.05). Univariate analysis on the entire set of data revealed eight factors, including tutors' performance, that were associated with a change score of the use of two or more outcome measures by individual physiotherapists after the educational programme. Conclusion: In this pilot trial it was not proven that tutor expertise in stroke care influences the actual use of outcome measures, but it warrants a future study with sufficient power to investigate the influence of the tutor. © The Author(s), 2009.

Bij kinderen die te vroeg geboren worden of met een te laag geboortegewicht voor de zwangerschapsduur (‘small for gestational age’ (SGA)) is intensieve zorg en nazorg gewenst. Knelpunten hierbij zijn de vaak gedeelde zorg door kinderartsen, huisartsen, jeugdgezondheidszorg (jgz) en andere professionals voor de zeer te vroeg geboren kinderen (< 32 zwangerschapsweken), en het signaleren van mogelijke later ontstane gezondheidsproblemen bij de matig vroeg geboren kinderen (na 32-37 zwangerschapsweken). De multidisciplinair ontwikkelde en evidencebased jgz- richtlijn ‘Te vroeg en/of small for gestational age (SGA) geboren kinderen’ is relevant voor alle professionals betrokken bij de zorg voor deze groep kinderen. De belangrijkste aanbevelingen zijn: (a) tijdig en volledig overdragen van gegevens na ontslag uit ziekenhuis, (b) gestructureerde gegevensuitwisseling bij gedeelde nazorg, (c) aanwijzen van een casemanager per kind, (d) corrigeren van de testleeftijd voor de mate van vroeggeboorte bij ontwikkelingsonderzoek, en (e) mogelijkheid van gebruik van speciale curves en normen voor vroeggeboren kinderen bij het beoordelen van de groei en ontwikkeling.

Purpose. When introducing innovations to health care, it is important to gain insight into determinants that may facilitate or impede the introduction, in order to design an appropriate strategy for introducing the innovation. To obtain an overview of determinants of innovations in health care organizations, we carried out a literature review and a Delphi study. The Delphi study was intended to achieve consensus among a group of implementation experts on determinants identified from the literature review. Data sources. We searched 11 databases for articles published between 1990 and 2000. The keywords varied according to the specific database. We also searched for free text. Forty-four implementation experts (implementation researchers, programme managers, and implementation consultants/advisors) participated in the Delphi study. Study selection. The following studies were selected: (i) studies describing innovation processes, and determinants thereof, in health care organizations; (ii) studies where the aim of the innovations was to change the behaviour of health professionals; (iii) studies where the health care organizations provided direct patient care; and (iv) studies where only empirical studies were included. Data extraction. Two researchers independently selected the abstracts and analysed the articles. The determinants were divided into four categories: characteristics of the environment, characteristics of the organization, characteristics of the user (health professional), and characteristics of the innovation. When analysing the determinants, a distinction was made between systematically designed and non-systematically designed studies. In a systematic study, a determinant analysis was performed and the innovation strategy was adapted to these determinants. Furthermore, the determinants were associated with the degree of implementation, and both users and non-users of the innovation were asked about possible determinants. In the Delphi study, consensus was defined as agreement among 75% of the experts on both the influence of a determinant and the direction towards which that influence tended (i.e. facilitating, impeding, or neutral). Results. From the initial 2239 abstracts, 57 studies were retrieved and 49 determinants were identified that affected (impeded or facilitated) the innovation process. The experts identified one other determinant. Seventeen studies had a more-or-less systematic design; the others did not. After three rounds, consensus was reached on the influence of 49 out of 50 determinants. Conclusion. The results of the literature review matched those found in the Delphi study, and 50 potentially relevant determinants of innovation processes were identified. Many of the innovation studies had several methodological flaws, such as not adjusting innovation strategies to relevant determinants of the innovation process, or that data on determinants were gathered only from non-users. Furthermore, the degree of implementation was evaluated in several ways, which made comparison difficult. © International Society for Quality in Health Care and Oxford University Press 2004; all rights reserved.

Objective and design. The Leiden Developmental Care Project explored the effects of the basic elements of developmental care (DC: the use of incubator covers and nests) and the Newborn Individualized Developmental Care and Assessment Program (NIDCAP) with individual behavior observations for very premature infants less than 32 weeks of gestation. Design. Two consecutive randomized trials in two Dutch neonatal intensive care units: standard care versus DC and DC versus NIDCAP care. Method. Questionnaires completed by parents during admission (parental stress and confidence and social support) and follow-up at 1 year of corrected age (parental stress, behavior and health-related quality of life of the children) and by caregivers after implementation of the NIDCAP. Results. Quality of life and parental stress were not influenced by either type of intervention. Limited effects were found on competence child behavior at 1 year of age, when children who had received DC showed more mastery motivation (curiosity, persistence and obedience). When the intervention duration was longer, the behavioral observations had a positive effect on the social relatedness behavior of the children at 1 year. Parents, nursing and (para)medical personnel in the neonatal unit reported a positive effect of NIDCAP care on comfort and well-being of the children during admission to the neonatal unit. Conclusion. Although only limited effects on outcome were found, parents and personnel in the neonatal units were positive about the effects of the interventions on comfort and well-being of the very premature infants. A complete cost-benefit analysis in the Dutch setting is important because of the high training costs of the NIDCAP. Future research should consider a longer intervention duration, use of comfort or pain measures and a qualitative evaluation by parents and caregiving personnel.

Background This study aims to give insight into the opinions of maternity care professionals and other stakeholders on the integration of midwife-led care and obstetrician-led care and on the facilitating and inhibiting factors for integrating maternity care. Methods Qualitative study using interviews and focus groups from November 2012 to February 2013 in the Netherlands. Seventeen purposively selected stakeholder representatives participated in individual semi-structured interviews and 21 in focus groups. One face-to-face focus group included a combined group of midwives, obstetricians and a paediatrician involved in maternity care. Two online focus groups included a group of primary care midwives and a group of clinical midwives respectively. Thematic analysis was performed using Atlas.ti. Two researchers independently coded the interview and focus group transcripts by means of a mind map and themes and relations between them were described. Results Three main themes were identified with regard to integrating maternity care: client-centred care, continuity of care and task shifting between professionals. Opinions differed regarding the optimal maternity care organisation model. Participants considered the current payment structure an inhibiting factor, whereas a new modified payment structure based on the actual amount of work performed was seen as a facilitating factor. Both midwives and obstetricians indicated that they were afraid to loose autonomy. Conclusions An integrated maternity care system may improve client-centred care, provide continuity of care for women during labour and birth and include a shift of responsibilities between health care providers. However, differences of opinion among professionals and other stakeholders with regard to the optimal maternity care organisation model may complicate the implementation of integrated care. Important factors for a successful implementation of integrated maternity care are an appropriate payment structure and maintenance of the autonomy of professionals.

Gemeenten en zorgorganisaties kijken steeds vaker over grenzen van sectoren heen vanwege de decentralisatie van ondersteuning aan langdurig zieken en ouderen. De samenwerking bij een dergelijke integrale aanpak kent verschillende uitdagingen, die in opleiding en training kunnen worden geoefend. Dit artikel beschrijft het proces om te komen tot een serious game voor het oefenen van de belangrijkste uitdagingen bij complexe multidisciplinaire samenwerking in zorg en welzijn. Op basis van literatuuronderzoek en interviews met professionals zijn vier leerdoelen opgesteld: het onderscheiden van de meerwaarde van de verschillende professionals, het communiceren met de verschillende professionals, het ontwikkelen van en het handelen naar een teamgerichte focus en het reflecteren op de samenwerking en de eigen rol hierin. In een prototype van de serious game combineerden we deze leerdoelen met gaming elementen, zoals tijdsdruk, het omgaan met tegenstrijdige belangen, het uitwisselen van unieke informatie, cross-training en stapsgewijze spelacties. De game is in drie pilotsessies gespeeld met professionals uit zorg en welzijn. Direct na het spelen werd met behulp van een evaluatieprotocol de game geëvalueerd en aangepast. De leerdoelen werden herkend en de spelvorm sluit aan bij de wensen van de praktijk. Deze studie biedt inzicht in de bouwstenen om multidisciplinaire samenwerking te optimaliseren en laat zien hoe een laagdrempelige, praktijkgerichte simulatietraining kan worden ontwikkeld.

Objective: Prevailing measures of subjective caregiver burden either have no overall summary score or do not consider the relative importance caregivers attach to different dimensions of burden. Our aim was to assess which dimensions informal caregivers perceive as being important to their overall burden from care giving. Design: Cross-sectional. Subjects: Data were pooled from two Dutch samples of primary informal caregivers covering a wide range of chronic care-giving situations: caregivers for stroke survivors (n = 196) and caregivers for individuals with rheumatoid arthritis (RA) (n = 131). Main measures: Subjective burden of care giving was assessed using the Caregiver Reaction Assessment (CRA) and the Self-Rated Burden scale (SRB). Results: In the total sample four of the five dimensions of the CRA were found to contribute to the overall subjective burden experienced by informal caregivers. In the individual stroke and RA samples only two of the five dimensions emerged as relevant. SRB scores were significantly higher for caregivers of stroke patients, but no differences were found for the five dimensions of the CRA between the two samples. Conclusions: The dimensions of CRA are not equally important to the overall subjective burden of informal caregivers. To assess overall subjective burden, a measure based on a caregiver's own assessment of burden such as SRB needs to be used in addition to prevailing measures. © Arnold 2004.

Bij een verblijf op een hoogte van meer dan 2500 m kunnen symptomen ontstaan van weefselhypoxie, in het bijzonder long- en hersenoedeem. Patiënten met bestaande gezondheidsproblemen kunnen eerder, meer of ernstiger klachten verwachten. Voor een aantal van hen is een verblijf op grote hoogte dan ook af te raden of alleen mogelijk als bepaalde maatregelen worden genomen. De adviserend arts dient op de hoogte te zijn van de reacties van het menselijk lichaam op hypoxie en inzicht te hebben in (ontsporingen van) het acclimatisatieproces op hoogte. Elke patiënt met een ziekte die kan interfereren met zuurstoftekort, verdient een individuele beoordeling. De belangrijkste absolute en relatieve contra-indicaties zijn: cardiale en pulmonale aandoeningen, hemoglobineafwijkingen, diabetes mellitus, hypertensie, epilepsie, ernstige obesitas, nierziekten en zwangerschap. Voorwaarde voor een hoge tocht bij bestaande gezondheidsproblemen is dat ter plekke medische zorg snel en adequaat kan worden geleverd.

Objectives: In the Netherlands, approximately one-third of births are planned home births, mostly supervised by a midwife. The relationship between maternal demographic factors and home births supervised by midwives was examined. Design: Cross-sectional study. Setting: Dutch national perinatal registries of the year 2000. Population: All women starting their pregnancy care under the supervision of a midwife, because these women have the possibility of having a planned home birth. Methods: The possible groups of birth were as follows: planned home birth or short stay hospital birth, both under the supervision of a midwife, or hospital birth under the supervision of an obstetrician after referral from the midwife during pregnancy or birth. The studied demographic factors were maternal age, parity, ethnicity and degree of urbanisation. Probabilities of having a planned home birth were calculated for women with different demographic profiles. Main outcome measure: Place of birth. Results: In all age groups, the planned home birth percentage in primiparous women was lower than in multiparous women (23.5% vs 42.8%). A low home birth percentage was observed in women younger than 25 years. Dutch and non-Dutch women showed almost similar percentages of obstetrician-supervised hospital births but large differences in percentage of planned home births (36.5% vs 17.3%). Fewer home births were observed in large cities (30.5%) compared with small cities (35.7%) and rural areas (35.8%). Conclusions: This study demonstrates a clear relationship between maternal demographic factors and the place of birth and type of caregiver and therefore the probability of a planned home birth. © RCOG 2004.

Objective: To estimate the costs and effects of different treatment strategies with intrapartum antibiotic prophylaxis to prevent early-onset group B streptococcal (GBS) disease in the Netherlands. The treatment strategies include a risk-based strategy, a screening-based strategy, a combined screening/risk-based strategy and the current Dutch guideline. Design: Cost-effectiveness analysis based on decision model. Setting Obstetric care system in the Netherlands. Population/Sample Hypothetical cohort of 200,000 neonates. Methods: A decision analysis model was used to compare the costs and effects of different treatment strategies with no treatment. Baseline estimates were derived from literature and a survey among parents of children affected by GBS disease. The analysis was performed from a societal perspective, and costs and effects were discounted at a percentage of 3%. Main outcome measures Cost per quality adjusted of life-year (QALY). Result The risk-based strategy will prevent 352 cases of early-onset GBS for € 5.0 million, indicating a cost-effectiveness ratio of € 7600 per QALY gained. The combined screening risk-based strategy has comparable results. The current Dutch guideline resulted in lower effects for higher costs. The screening-based strategy shows the highest reduction in cases of early-onset GBS, however, at a cost-effectiveness ratio of € 59,300 per QALY gained. Introducing the polymerase chain reaction (PCR) test may lead to a more favourable cost-effectiveness ratio. Conclusion: In the Dutch system, the combined screening/risk-based strategy and the risk-based strategy have reasonable cost-effectiveness ratios. If it becomes feasible to add the PCR test, the cost-effectiveness of the combined screening/risk-based strategy may even be more favourable. © RCOG 2005.

Hand dermatitis is a prevalent disease with an episodic, chronic character. The use of medical resources is high and is often related to reduced (work) functioning. The burden is therefore high for patients and society. Management of hand dermatitis is often unsatisfactory, and for this reason prevention is important. The effectiveness of prevention programmes is, however, unknown. This study evaluates if comprehensive prevention programmes for hand dermatitis, that include worker education as an element, are effective on occurrence, adherence to preventive measures, clinical outcomes and costs compared to usual care or no intervention. The literature was systematically searched using PubMed and Embase, from the earliest to January 2010 for relevant citations. The methodological quality was assessed by two reviewers using the Cochrane criteria. The GRADE approach was used to determine the level of evidence. After reading the full text articles, 7 publications met our inclusion criteria. We found that there is moderate evidence for the effect of prevention programmes on lowering occurrence and improving adherence to preventive measures, and low evidence for the effect on improving clinical outcomes and self-reported outcomes. No studies reporting on costs were found. It can be concluded that there is moderate evidence for the effectiveness of prevention programmes of hand dermatitis versus usual care or no intervention. However, more high quality studies including cost-effectiveness are needed. © 2011 John Wiley & Sons A/S.

Every year 7000 people die from obesity and another 13 000 people die by wrong diets in The Netherlands. Part of this problem can be solved when the communication between general practitioners (GPs) and patients about nutrition and diets improves. There are four activities that can contribute greatly to the communication between GPs and their patients. (1) GPs can ask nonjudgemental questions that help to understand their patients' perspective on the illness, its causes and possible treatments. (2) GPs can listen carefully to their patients' replies and try to pick up clues to their understanding as well as their ability to adhere to a recommended treatment. (3) GPs can work with patients and family members to set realistic and achievable goals for behavioural change. (4) GPs can involve their patients in active problem solving. The role that practitioners play in changing patients' behaviour to healthy lifestyles is more similar to a coach. They should be along the sideline, empowering patients, helping them develop their own healthy lifestyles. When GPs apply these principles in daily practice, they will find out that they can effectively influence the nutrition patterns of their patients. © 2005 Nature Publishing Group. All rights reserved.

Background. To date, mental health problems and mental workload have been increasingly related to long-term sick leave and disability. However, there is, as yet, no structured protocol available for the identification and application of an intervention for stress-related mental health problems at the workplace. This paper describes the structured development, implementation and planning for the evaluation of a return-to-work intervention for sick-listed employees with stress-related mental disorders (SMDs). The intervention is based on an existing successful return-to-work intervention for sick-listed employees with low back pain. Methods. The principles of Intervention Mapping were applied to combine theory and evidence in the development, implementation and planning for the evaluation of a participatory workplace intervention, aimed at an early return-to-work for sick-listed employees with SMDs. All stakeholders were involved in focus group interviews: i.e. employees recently sick-listed with SMDs, supervisors and occupational health professionals. Results. The development of the participatory workplace intervention according to the Intervention Mapping principles resulted in a structured return-to-work intervention, specifically tailored to the needs of sick-listed employees with SMDs. Return-to-work was proposed as a behavioural change, and the Attitude - Social influence - self-Efficacy model was identified as a theoretical framework. Stakeholder involvement in focus group interviews served to enhance the implementation. The cost-effectiveness of the intervention will be evaluated in a randomised controlled trial. Conclusion. Intervention Mapping was found to be a promising method to develop interventions tailored to a specific target group in the field of occupational health. Trial registration. ISRCTN92307123. © 2007 van Oostrom et al; licensee BioMed Central Ltd.

Objective. Assessing whether the initiation of insulin therapy in patients with diabetes mellitus type 2 can be delivered as effectively in a structured transmural care model as in the more usual outpatients structure. Design. Retrospective comparative cohort study. Method. In 1997 data were collected from 52 patients with diabetes mellitus type 2 all of whom were above 40 years of age and transferred to insulin therapy in 1993: 25 in a transmural care setting and 27 in an outpatients setting, both in Amsterdam, the Netherlands. Both groups were treated according to one protocol concerning the initiation and monitoring of insulin therapy, treatment goals and follow-up. Outcome measures were: percentage of glycated haemoglobin (HbA1c), health status, self-care behaviour and patient satisfaction. In 1993 the mean age was (transmural/outpatients setting): 67.5/65.3 years; percentage of men: 32%/48%; mean duration of diabetes: 7.3/10.6 years; HbA1c: 9.1%/9.3%; mean body mass index: 27.4/29.1 kg/m2. Results. In the period 1993-1997 the mean HbA1c decreased from 9.1% to 7.2% in the transmural care group and from 9.3% to 7.6% in the outpatients care group (both: p = 0.000). The percentage of patients with poor glycaemic control (HbA1c > 8%) decreased from 60 to 8 in the transmural care group and from 59 to 15 in the outpatients care group. The percentage of patients with good glycaemic control (HbA1c < 7%) increased from 4 to 52 in the transmural care group and from 11 to 30 in the outpatients care group. No statistically significant differences were found between the patient groups with respect to health status, self-care behaviour and patient satisfaction. Conclusion. The transfer of patients with diabetes mellitus type 2 insulin therapy in a shared care setting was at least as effective as in an outpatients setting. Chemicals/CAS: Hypoglycemic Agents; Insulin, 11061-68-0

Objectives Many European countries face challenges in long-term care for older people, such as the growing number of older people requiring care, the increasing complexity of their health care problems, and a decreasing workforce that is inadequately prepared. Optimizing the staff and skill mix of health care teams may offer part of the solution for these challenges. The aim of this study was to obtain insight into the development of teams in terms of staff and skill mix, and the influence of staff and skill mix on quality of care, quality of life, and job satisfaction. Methods Seven teams in elderly care in the Netherlands participated in this exploratory case study. From April 2013 to January 2015, a researcher followed the development of the teams, performed observations at the workplace and held interviews with team members, team captains, and (representatives of) clients. Data-analyses were carried out in MAXQDA 11, by coding interviews and analyzing themes. Results During the project, almost all teams became more diverse in terms of staff and skill mix. In general, there was a trend towards adding (more) higher-qualified health care workers (e.g. nurse) to the team, increasing communication with other disciplines, and enhancing skills of lower-qualified team members. A more diverse staff and skill mix had a positive effect on quality of care and quality of life of clients, and on job satisfaction, but only under certain contextual conditions. Important contextual conditions for successful functioning of a diverse team were a shared view of care by all team members, good communication, autonomy for professionals, and a safe team culture. Conclusion A more diverse staff and skill mix, in combination with positive contextual conditions, can result in improved quality of care, quality of life, and job satisfaction. However, a “one size fits all” blueprint for the optimal staff and skill mix, that suits each team and organization, does not exist. This depends on the context, and should be based on the needs of the clients and possible future changes in these needs.

Objective: To evaluate the cost-effectiveness and cost-utility of a return to work (RTW) program for workers on sick-leave due to low back pain (LBP), comparing a workplace intervention implemented between 2 to 8 weeks of sick-leave with usual care, and a clinical intervention after 8 weeks of sick-leave with usual care. Design: Economic evaluation alongside a randomised controlled trial (RCT). Study population: Workers sick-listed for a period of 2 to 6 weeks due to LBP. Interventions: 1. workplace assessment, work modifications and case management). 2. physiotherapy based on operant behavioural principles. 3. usual care: provided by an occupational physician. Outcomes: The primary outcome was return to work (RTW). Other outcomes were pain intensity, functional status, quality of life and general health. The economic evaluation was conducted from a societal perspective. Outcomes were assessed at baseline (after 2-6 weeks on sick-leave), and 12 weeks, 26 weeks, and 52 weeks after the first day of sick-leave. Results: The workplace intervention group returned to work 30.0 days (95% CI=[3.1, 51.3]) earlier on average than the usual care group at slightly higher direct costs (ratio of 1 day: €19). Workers in the clinical intervention group that had received usual care in the first 8 weeks returned to work 21.3 days (95% CI= [-74.1, 29.2]) later on average. The group that had received the workplace intervention in the first 8 weeks and the clinical intervention after 8 weeks returned to work 50.9 days (95% CI=[-89.4, -2.7]) later on average. A workplace intervention was more effective than usual care in RTW at slightly higher costs and was equally effective as usual care at equal costs on other outcomes. A clinical intervention was less effective than usual care and associated with higher costs. Conclusion: The workplace intervention results in a safe and faster RTW than usual care at reasonable costs for workers on sick-leave for two to six weeks due to LBP. © 2006 Springer Science+Business Media, LLC.